I was forwaded a link to this blog post in an email. The author, a neurosurgeon, apparently feels threatened by the new found attention that primary care is receiving. As an academic physician, I suppose he offers an opinion that deserves serious comment. He offers the following as a strawman to knock down:

Their argument goes something like this:  “If we invested more in  primary and preventive care, we could keep people from getting sick and  avoid the expenses of costly surgical procedures and other medical  interventions. This would result in improved quality and lower cost. One way to accomplish this is to increase reimbursement for primary care  services and reduce reimbursement for surgical specialty services. This  will incentivize medical students to enter primary care, where we need  more doctors, and deter students from entering surgical specialties  where we already have too many doctors.”

He finds the following (which he believes to be incorporated in this argument) to be not supported by evidence:

“If we invested more in primary care we could keep people from getting sick and save money.”

“We need to increase reimbursement for primary care services and  reduce reimbursement for surgical specialty services. This will
incentivize medical students to enter primary care, where we need more  doctors, and inhibit students from entering surgical specialties where  we already have too many doctors.”

“We need to remove the monetary incentives that lead surgeons to operate on patients solely for monetary reasons.”

He then offers the following in the way of conclusion:

For a carotid endarterectomy, my most common operation, Medicare pays  about $1,000, which covers my services for immediate preoperative care, surgical care and all postoperative care for 90 days. In my practice,  carotid surgery is recommended almost exclusively for symptomatic,  severe carotid stenosis – where we have excellent data indicating that low risk endarterectomy is highly effective for stroke prevention.  Unlike the unfocused preventive care discussed above, the NNT to prevent one stroke at two years is six. In other words, I practice preventive  care that is highly effective and precisely targeted to the group most  likely to benefit. [emphasis mine]

Someone already referred him to the work of Barbara Starfield which refutes his entire argument against an investment in primary care. I couldn’t resist formulating a response to his concluding statement:

For a carotid endarterectomy, my most common operation,

Data is real clear: for this operation outcomes are better in centers, and outcomes are better when a dedicated operator does them. Is this his full time job or is he a hobbyist? What are his outcomes? I agree that Primary Care is not the answer to everything, but neither is gonzo surgery…

Medicare pays about $1,000, which covers my services for immediate preoperative care, surgical care and all postoperative care for 90 days.

My specialty colleagues inevitable response, it isn’t the doctors fault….Value based purchasing and bundled payments will change that perspective and make someone responsible for the totality of costs for the 90 days…wonder if he knows that the $1000 might be $500 or even $0 if things don’t go well?

In my practice, carotid surgery is recommended almost exclusively for symptomatic, severe carotid stenosis – where we have excellent data indicating that low risk endarterectomy is highly effective for stroke prevention.
Again, “My practice.” Is the we the royal literature we, the local practice we, or the I think I do a good job we…

Unlike the unfocused preventive care discussed above, the NNT to prevent one stroke at two years is six.

Turns out critical carotid stenosis is not a random event. From this “population based” study:

Prevalence of and risk factors associated with carotid artery stenosis: the Tromsø Study.

Cholesterol, HDL cholesterol, fibrinogen, systolic blood pressure levels and current smoking were independently associated with carotid artery stenosis in both women and men. The presence of carotid stenosis was significantly associated with a history of cerebrovascular disease, coronary heart disease and peripheral artery disease. For each 10% increase in the degree of carotid stenosis, the risk of having had a cerebrovascular event increased by 26%…

I guess he’s worried we’ll cut into his “preventive” mission.

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